Simple Medical Worksheet Outline

****All that is bolded and underlined below, should be on your worksheet (bolded & underlined), so they are able to view and distinguish between the different fields. I would also single space it so you can fit more onto one page****

MEDICAL HISTORY

Name of Patient

Date of Birth

Insurance information

Parent’s Name

Parent’s Contact Information

ALLERGIES (this needs to be in red bolded font and highlighted)

DIAGNOSIS (list these individually, on separate lines)

Spina Bifida

Hydrocephalus

Neurogenic Bladder (must catheterize)

MEDICATIONS (list the name, dosage amount, and dosage schedule – you also can google how to abbreviate dosage schedule EX: prn, bid, tid)

DOCTORS (the one’s you see on a regular schedule, what specialty, list their name, address, and telephone, you can do this in two columns and use abbreviation for their specialty)

Dr. Joe Smith – General Practitioner/Primary Care Physician (GP/PCP)

1234 Medical Park

City, State, Zip

(555) 555-5555

Dr. John Doe – Neurologist

4567 Medical Plaza Dr

City, State, Zip

(555) 555-5555

*********** You should make this as a Word document and save it, so you can update information. It is a good idea to make multiple copies. Keep one in your purse, in your car, in your child’s backpack, file one with the school, at home where you store emergency numbers and information, leave a copy out for the babysitter in case of an emergency, file a copy in the medical binder, take them to all doctor’s appointments (either give them the sheet or have them make a copy), and bring them to the ER or Urgent Care facilities if your child needs to see a doctor quickly. This helps you know all the information many doctor’s offices and ER’s need to know to help determine the best care for your child. Keeping it up to date will also help you keep track of everything.*************************